Domain 11. Safety-protection
Class 2. Physical injury
Diagnostic Code: 00312
Nanda label: Adult pressure injury
Diagnostic focus: Pressure injury
Nursing diagnosis is an evidence-based practice that enables nursing staff to deliver top-notch care for their patients. In particular, adult pressure injury, sometimes known as bedsores or decubitus ulcers, is a common yet potentially serious condition often encountered by nurses. The goal of nursing diagnosis is to develop a comprehensive plan of care which can effectively address the needs of individuals with this condition. In this post, we provide detailed information about adult pressure injury, NANDA nursing diagnosis definition, defining characteristics, related factors, at-risk population, associated conditions, suggestions for use, suggested alternative NANDA nursing diagnosis, usage tips, NOC Outcomes, evaluation objectives and criteria, NIC Interventions, nursing activities, conclusion, and also 5 FAQs to help nurses gain a better understanding of this particular nursing diagnosis.
NANDA Nursing Diagnosis Definition
NANDA (North American Nursing Diagnosis Association) International is a globally recognized organization which defines nursing diagnoses in terms of expected outcomes, defining characteristics, and nursing interventions. According to NANDA International, nursing diagnosis Adult Pressure Injury is defined as a pattern of impaired skin integrity due to intense persistent pressure or shear.
Defining Characteristics
The defining characteristics of nursing diagnosis Adult Pressure Injury include subjective findings, such as the patient reporting pain or discomfort related to the pressure injury, and objective findings, such as the presence of redness and swelling at the site. Other objective findings may be present, depending on the location and severity of the injury. For example, the presence of breakdown of the skin tissue, as well as the presence of exposed bone or joint capsule, may also be observed.
The main related factor for nursing diagnosis Adult Pressure Injury is prolonged immobility. Prolonged immobility leads to an increase in pressure on certain areas of the body, while decreasing circulation to the area. Decreased circulation causes further tissue damage and increases the risk of infection. Other factors, such as age, obesity, metabolic conditions and environmental factors can also contribute to the development of pressure injuries.
At Risk Population
At-risk populations are particularly susceptible to developing pressure injuries, due to underlying medical conditions or other contributing factors. Such populations include older adults, disabled individuals, those who are bedridden and those who are in long-term care facilities. Patients undergoing long-term treatment and rehabilitation programs may also be more vulnerable to developing this condition.
Associated Conditions
Adult Pressure Injury is often associated with other conditions, such as malnutrition, dehydration, urinary tract infections, sepsis and gangrenous pressure sores. Additionally, these injuries are often symptomatic of underlying disease processes, such as diabetes and heart disease. An accurate diagnostic assessment is essential for understanding the extent of the injury, prognosis and treatment plan.
Suggestions of Use
In order to prevent and treat pressure injuries, nurses should suggest the following preventive measures: use of special foam mattresses or pressure-relieving devices, repositioning and turning patients at least every two hours, adequate nutrition and hydration, good hygiene practices and skin care, proper mobilization tailored to each individual’s needs, frequent assessments, and appropriate wound care.
Suggested Alternative NANDA Nursing Diagnosis
Alternative NANDA Nursing Diagnoses that may be given for Adult Pressure Injury include Impaired Tissue Integrity, Impaired Skin Integrity, Risk for Impaired Tissue Integrity and Risk for Infection. Each of these diagnoses provide a different focus that may be beneficial in the development of individualized nursing plans of care.
Usage Tips
When using the Nursing Diagnosis Adult Pressure Injury, it is important to remember that it applies only to adult patients. It is also important to recognize that although this diagnosis can be used in many settings, some organizations may require additional information regarding diagnosis, interventions, and evaluation criteria.
NOC Outcomes
The NOC Outcomes associated with Nursing Diagnosis Adult Pressure Injury includes skin integrity, comfort level, mobility, tissue perfusion, nutrition, risk control, health education, and pain control. Each of these outcomes has its own set of measurable criteria and indicates a different aspect of the patient's response to the pressure injury.
Evaluation Objectives and Criteria
Evaluation objectives and criteria are necessary for successful implementation of the nursing plan of care. Evaluation criteria should identify the nurse's expected outcome for the patient, such as comprehension of wound care instructions, improved skin integrity, comfort level, and mobility. A clear set of evaluation criteria will provide the nurse with measurable markers of success, allowing the nurse to assess the effectiveness of the plan.
NIC Interventions
The NIC Interventions associated with Adult Pressure Injury includes Wound Healing, Support Positioning, Edema Management, Nutrition Monitoring, Skin Care, Mobility and Education. Each intervention is designed to help patients manage their care and improve the overall efficacy of their wound-care regimen.
Nursing Activities
The primary nursing activities associated with Adult Pressure Injury involve assessing the patient for signs and symptoms of the condition, as well as monitoring changes in the patient’s skin. Additionally, nurses should provide wound care as indicated, ensuring that the patient’s skin is properly cleansed, moisturized, and protected. Nurses should also encourage the patient to remain active and stay off the affected area.
Conclusion
Nursing Diagnosis Adult Pressure Injury is an important part of the health care process and requires a comprehensive approach to management. By understanding the definition, characteristics, associated factors, at-risk populations, and associated conditions of adult pressure injury, nurses are able to develop appropriate plans of care for patients. Additionally, nurses should be aware of prevention strategies and treatment options, as well as the NOC Outcomes, evaluation objectives, and NIC interventions necessary for proper management of the condition.
FAQs
1. What is Nursing Diagnosis Adult Pressure Injury?
Nursing Diagnosis Adult Pressure Injury is a pattern of impaired skin integrity due to intense persistent pressure or shear, often seen in individuals who are bedridden, older, disabled, or in long term care facilities.
2. What are the Defining Characteristics?
The defining characteristics of nursing diagnosis Adult Pressure Injury include subjective findings, such as the patient reporting pain or discomfort related to the pressure injury, and objective findings, such as the presence of redness and swelling at the site. Other objective findings may be present, depending on the location and severity of the injury.
3. What are the Related Factors?
The main related factor for nursing diagnosis Adult Pressure Injury is prolonged immobility. Prolonged immobility leads to an increase in pressure on certain areas of the body, while decreasing circulation to the area. Decreased circulation causes further tissue damage and increases the risk of infection.
4. Who is At Risk for Developing This Condition?
Groups which are particularly at risk for developing adult pressure injury include older adults, disabled individuals, those who are bedridden and those who are in long-term care facilities. Patients undergoing long-term treatment and rehabilitation programs may also be more vulnerable to developing this condition.
5. What Is Involved in the Treatment Plan?
When treating adult pressure injury, nurses should suggest the following preventive measures: use of special foam mattresses or pressure-relieving devices, repositioning and turning patients at least every two hours, adequate nutrition and hydration, good hygiene practices and skin care, proper mobilization tailored to each individual’s needs, frequent assessments, and appropriate wound care. Additionally, nurses should monitor the patient for signs and symptoms of the condition, as well as monitor changes in the patient’s skin, provide wound care as indicated, and encourage the patient to remain active and stay off the affected area.
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